Knowledge is power, so the saying goes. The power of local knowledge, according to a major bank, should never be underestimated. Needing no convincing as to the truth of this statement is the COSS who worked at Acton West on 24th June last year, a day when safety - not to mention two rail grinders - was absolutely on the line.

Shortly after midnight, a gang of five men drove onto a dirt track off Acton’s Noel Road, weaving around the potholes en route to their worksite. A routine ultrasonic inspection of the Down Relief line - one of the Great Western’s four tracks - had identified rolling contact fatigue for a distance of around 280 yards in the vicinity of Ealing Broadway Station. Rail grinding was arranged by the local Track Maintenance Engineer. The West Ealing delivery unit had no permanent staff capable of undertaking such work so a team from Reading - 30 miles further west - was drafted in. These were the men who had just passed through the access gate.

The condition of the roadway brought their van to a halt after 200 yards, more than half-a-mile short of their worksite. Faced with this air gap, the COSS decided to unload his machines, place them on the Up Relief and push them to where they were needed. But he had no detailed knowledge of the area. Expecting four lines, he found himself confronted by six - the Up & Down Mains (furthest away), the Up & Down Reliefs, a bi-directional goods line and, closest to him, a disused siding.

The PICOP had been granted a possession of the Up & Down Relief lines from 5m 37ch to 9m 30ch. The Noel Road access is at 4m 70ch; the gang’s van was close to the 5 milepost. At 0037, unaware that the lines alongside him were outside the possession, the COSS received the Engineering Supervisor’s authority to start work. He regurgitated the contents of his Rimini pack and told his team to assemble their machines on the Up Relief.

He regurgitated the contents of his Rimini pack and told his team to assemble their machines on the Up Relief.

As the Grinding Supervisor Manager walked towards Ealing Broadway Station to mark up their work, he unexpectedly encountered a Possession Limit Board. Suspecting that all was not well, he rang the COSS and asked him to check the paperwork. The COSS retired to the van to unearth it.

It was now 0105. 2P01 pulled away from Ealing Broadway’s Up Main platform, accelerating towards Acton West Junction. Routed across to the Up Relief, it hit the crossover at 52mph. Moments later, the driver saw the reflective strips of three men’s HV clothing - one of them spotted the train’s approach. The horn was sounded; the gang member shouted a warning; the men scattered towards the goods line. In front of the driver, two machines then loomed into view. He applied the emergency brake but a collision was inevitable, rupturing the train’s fuel tank and damaging its braking system. It was only by great fortune that no physical injuries were sustained.

An NV3 rail grinding machine.

Picture Source: RAIB Rail Accident Report (Crown Copyright)

The COSS had considerable railway experience - more than eight years - but had been a COSS for only ten months. His Rimini pack identified the grinding location using miles and chains; the possession limits were given by points and signal numbers. The mileage of the Noel Road access point was not recorded. Included was an extract from the Sectional Appendix but no relevant information was marked on it.

The grinding team’s patch was huge, extending tens of miles from Reading in all directions. Despite Network Rail Standard NR/SP/OHS/019 ("The safety of people working on or near the line") mandating that COSSs are familiar with their work location, this COSS hadn't undertaken a site visit during his six-month stint looking after the team, neither had he ever been to the Noel Road access point. Another gang member had picked up the Rimini pack 24 hours beforehand, leaving the COSS with no opportunity to familiarise himself with it. A discussion with the ES about the extent of the possession only led to confusion.

The ES had a busy night ahead of him. His worksite contained five groups spread over a distance of four miles; three of them involved train or machine movements. Having authorised the others to start work, he was to act as COSS for some S&C grinding.

Responsible for that night’s paperwork was the grinding team’s manager who had recently returned from sick leave. It was his intention that the group would drive alongside the railway to the possession limit before completing their journey on foot - the road however was almost half-a-mile too short.

Although he had taken the assessment, the manager had not reached the standard necessary to be a ‘Core Planner’, neither had he been mentored. The Works Planner who would normally have carried out these duties had a backlog, having recently suffered a period of sickness himself. As a consequence, nobody checked the contents of the Rimini pack.

An oversight resulted in the grinding work not being recorded on the possession plan until T-2 weeks. No-one from Reading attended the delivery unit’s planning meetings; the same was true of the PICOP’s briefing meeting from which no details were fed back. Despite their inclusion on the agenda, access arrangements didn’t come up for discussion.

Looking west along the Up Relief line towards Ealing Broadway Station.

Picture Source: RAIB Rail Accident Report (Crown Copyright)

RAIB’s inquiry report - which, for a change, saw the light of day a full six days before the regulatory 12 month time limit - found that the Rimini pack was deficient, lacking key and clear information, a fact compounded by the COSS’s lack of local knowledge. The COSS felt that his job was to implement the pack’s provisions rather than critically check them - a concern raised by many before Rimini was born but discounted by Network Rail. The words 'chicken' and 'roost' come to mind. A track layout sign at the access point would have mitigated some of these factors but there wasn’t one.

The Engineering Supervisor was overworked. With three items of on-track machinery to manage, Network Rail’s Maintenance Planning Handbook allows an ES to also act as COSS only if there are no more than three groups in his worksite. Here, there were five.

Familiar causes reared their heads at Acton West. Paperwork was produced to fulfil bureaucratic commandments; nobody questioned whether it was fit for purpose and delivered value to the COSS. On-track staff were burdened by too many responsibilities. Lip-service had been paid to a glut of Standards, carefully crafted by tick-box strategists to relieve regulatory pressures but impossible to implement in the real world. We’ve heard them all before.

No doubt reviews will be triggered and action plans formulated, but nothing substantive will change. Sometime soon, I will cut and paste the previous paragraph into another rant. Unsurprisingly, Network Rail is now developing a Standard to place limits on the workload of safety critical roles. Like the others, this will be ignored when convenience or cost dictates. Despite evidence of their ineffectiveness, NR remains truly besotted with Standards. Its management has no understanding of the people it employs, only words on sheets of paper.

And what of RAIB? Where is its guiding light pointing? Recommendations demand a rebrief and a compliance audit; the development of some standard forms; a makeover for Rimini packs to achieve a consistent and user-friendly “appearance”. Existing arrangements must be reinforced.

This is what you get when investigators cannot be coaxed from their box. The Branch’s unwillingness to question the suitability of Standards - not just measure people against them - is magnificently determined. The words are never wrong, only those required to act upon them.

An access point sign on the West Coast at Tebay.

I will though commend RAIB's belief that a sign should be erected at every access point, providing basic information about the railway beyond it. In a dark sea shines a single beacon of common sense. If only it would get brighter.